Living will

Your Name

First Middle Last

Terminal Condition

A “Terminal Condition” is an incurable or irreversible condition for which the administration of life-sustaining procedures will serve only to postpone the moment of your death.

If two doctors certify in writing that you have a terminal condition, please choose one of the following:

Life-sustaining procedures are to be withdrawn and/or withheld.
Life-sustaining procedures shall be continued for a specified period of time.
Life-sustaining procedures shall be continued indefinitely.

“Life Sustaining Procedures” include any medical procedure or intervention that would serve only to prolong the dying process. It does not include any medical procedure or intervention for nutrition or hydration of the patient or considered necessary by the attending physician or advanced practice nurse to provide comfort or alleviate pain.

How long do you want to have life-sustaining procedures continued? (Days)

Do you wish to continue artificial nutrition or hydration if you have been diagnosed with a terminal condition?

Yes, indefinitely
Yes, for a specified period of time
No

How long do you want to have artificial nutrition or hydration continued? (Days)

Persistent Vegetative State (ID/CO) / Permanent Unconscious Condition (WA)

“Persistent Vegetative State” (Idaho and Colorado) generally means the patient can no longer think, feel anything, knowingly move, or be aware of being alive. “Permanent Unconscious Condition” (Washington) is an incurable and irreversible condition in which you have no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

If two doctors certify in writing that you are in a persistent vegetative state, please choose one of the following:

Life-sustaining procedures are to be withdrawn and/or withheld.
Life-sustaining procedures shall be continued for a specified period of time.
Life-sustaining procedures shall be continued indefinitely.

How long do you want to have life-sustaining procedures continued? (Days)

Do you wish to continue artificial nutrition or hydration if you have been diagnosed to be in a persistent vegetative state?

Yes, indefinitely
Yes, for a specified period of time
No

How long do you want to have artificial nutrition or hydration continued? (Days)

Living will

Health Care Directive

Step 1 of 3

Terminal Condition

Persistent Vegetative State (ID/CO) / Permanent Unconscious Condition (WA)

Other Directions

Resolution with Medical Power of Attorney

HIPAA Release and Communications

Full Name	Relationship to You	Telephone Number